Fish or cut bait on healthcare bill

07/24/17

Reader feedback at end

As of last Tuesday (July 18), the Senate healthcare bill (Better Care Reconciliation Act) appeared to have fallen short. There was much discussion of the reasons and who should be blamed, but from all indications the legislation wouldn’t draw the minimum number of votes (50 + tiebreaker vote by the vice president under the reconciliation process versus a 60-vote threshold for most bills) that would be required to overcome objections to bringing the measure to the Senate floor for consideration.

The following day, all GOP senators were invited to the White House for a discussion and lunch. And after the discussion part, a televised statement by the president – sitting with the senators and lecturing them on the political realities of the situation – was broadcast for all the world to see.

Was such a public dressing down of Senate Republicans warranted, and would it motivate the fractious GOP caucus to agree on some form of healthcare bill? Here’s our take: Back story – the talk – likely outcome (as of July 22).

A. Back story – Republicans spent years proclaiming their determination to repeal and replace GovCare, and after winning control of the Senate in the 2014 elections they used the reconciliation process to pass a bill covering the repeal part with a replacement plan to come later. All concerned knew this was a symbolic gesture – or trial run if you like - because the then president would veto the bill (as he did). Republicans send Obamacare repeal to Obama, Paige Winfield Cunningham, Washington Examiner, 1/6/16.

. . . while their efforts won’t succeed this year, Republicans are hopeful that by going through the exercise of crafting the bill, they have created a template for how they would be able to repeal most of the law if they win the presidency and keep control of the Senate next year.

The political calculus changed after Republicans retained control of both houses of Congress in the 2016 elections and won the presidency as well. Now GovCare repeal would be for real, so congressional Republicans would have to consider carefully whether – and on what conditions – they wanted to follow through on the matter.

There was no apparent consensus on the path forward, but two points emerged from preliminary discussions. First, GovCare shouldn’t be repealed without proposing a replacement plan. Second, the replacement plan would include some popular features of GovCare, notably the provision that no one can be denied healthcare insurance (HCI) coverage based on preexisting conditions.

SAFE agreed that complete repeal of GovCare wasn’t politically feasible and urged that a replacement plan be offered simultaneously so the proposed path forward wouldn’t need to be taken on faith. GovCare won’t really be repealed, and that’s fine, 12/5/16.

[If the replacement program was left for future discussion, it might turn out to involve] at least as much government control and cost as the current program. What we would like to see instead is a serious effort by Republicans to agree on the program they want, unify behind it, and get the bill enacted before the warm glow of the election results is forgotten.

It doesn’t have to be a perfect plan, there’s no such thing in politics, just a plan that would be clearly better than what exists now. And the Trump approach (health savings accounts, sale of HCI policies across state lines, block grant Medicaid coverage) might be a good place to start even if many details remain to be filled in.

It wasn’t easy or pretty, but House Republicans – with considerable help from the White House re bridging differences of opinion - passed H.R. 1628, the American Health Care Act (AHCA) on May 4. House healthcare bill draws heavy flak, 5/15/17.

In our view AHCA offered some major advantages, but there were withering objections from both side of the aisle and public support was eroding. Senate Republicans set out to write their own bill. Their ideas seemed to be all over the lot, and SAFE questioned whether the end result would necessarily be any better than AHCA. Senate healthcare do-over looks iffy, 5/22/17.

For all its imperfections, the AHCA would improve the current healthcare system somewhat. And the Senate could develop a better bill, if Republicans unite behind the goal of bringing down healthcare costs and clearly articulate how they propose to do so. If the primary focus becomes maintaining (and eventually growing) the HCI expansion that has occurred under the [Affordable Care Act], however, then Dr. Krauthammer [who had said single payer healthcare is inevitable] will be proven right.

To date, two versions of the Better Care Reconciliation Act (BCRA) have been posted on the Senate Budget Committee website.

From what we can gather, without attempting a detailed analysis, the BCRA (version 2) is less conservative than the AHCA – which wasn’t all that conservative to begin with. Is this the best Obamacare repeal we can do? Washington Examiner, 7/16/17.

•It is discouraging to see that $230 billion in Obamacare tax hikes will remain on the books if this bill passes. It is discouraging also to read that Senate Majority Leader Mitch McConnell, R-Ky., is apparently telling wavering centrists that the bill's cuts to Medicaid, which are not scheduled to take place until 2026, will never happen anyway.

•The Senate bill adopts a version of something Sens. Mike Lee, R-Utah, and Ted Cruz, R-Texas, proposed earlier. It would allow insurers to offer less-comprehensive and thus cheaper policies to those who prefer them. In theory, this would make cheaper insurance available and pull many healthy people back into the market who until now have chosen instead to pay the fine (or tax if you prefer) that Obamacare imposes on the uninsured. *** [But] unlike what [Lee] and Cruz proposed, the new version tries to create this market for catastrophic insurance without abandoning an Obamacare rule that requires all customers in the individual market and in small-groups insurance in a given state to be within the same risk pool. That might blunt or destroy its effectiveness in bringing insurance prices down.

Senator McConnell called for action on the BCRA (version 1) before the July 4th recess, but pulled back when it became clear that this bill wouldn’t receive the 50 votes needed to bring it to the Senate floor for discussion.

There was to be a vote on taking up the BCRA (version 2) during the week of July 10, but action was delayed again due to the declared opposition of four Republican senators and the illness (since diagnosed as brain cancer) of Senator John McCain. At that point, a proposal surfaced for a Senate vote to repeal GovCare and develop a replacement proposal later (a tack that had been rejected months earlier). Facing failure on healthcare, Republicans back to Obamacare repeal square one, Robert King & Kimberly Leonard, Washington Examiner, 7/18/17.

Any hope of a straight repeal seemingly vanished, however, when three GOP senators announced they would vote against it. At that point, the president – who had played a low-key role during work on the BCRA, supposedly out of deference to Senator McConnell’s vaunted prowess in steering legislation through the Senate – invited all Republican senators to the White House for lunch.

B. The talk – There were some exaggerations in the president’s pre-lunch remarks on July 19, but for the most part his pitch made sense:

Recap: (1) GovCare had been sold based on repeated “lies” by his predecessor, e.g., if you like your healthcare insurance you can keep it and just pay less for the coverage; (2) GovCare had failed to work and was, for all practical purposes, dead; (3) Republicans had promised the American people to “repeal and replace” GovCare; (4) A vote against GovCare reform would amount to saying one was OK with GovCare because the “obstructionist” Democrats weren’t going to suggest any solutions; (5) The Republican-controlled Congress should remain in Washington – for the entire month of August if necessary – to get the job done; and (6) The president would be sitting in his office, pen in hand, to sign whatever healthcare legislation Congress might agree on.

For more, here’s the video (11:21) that was televised. Notice the facial expression of Sen. Dean Heller (NV) when the president makes a remark about whether Heller wishes to continue being a US senator.

Beyond facts and logic, one must evaluate the president’s remarks from the standpoint of the various principals:

#PRESIDENT - Some observers suggest Mr. Trump should have been done more to “sell” the Republican healthcare plan instead of leaving this job for Speaker Paul Ryan, Senator Majority Leader McConnell, and other members of Congress. Consider how often his predecessor had spoken in favor of GovCare, using the “bully pulpit” of the presidency to put a controversial plan over the top.

OK, but the current president is far less of an ideologue and more of a dealmaker than his predecessor. He isn’t very interested in the details of the healthcare policies that are under discussion, and it might be a mistake for him to pretend otherwise.

A more telling criticism might be the way in which the president has zig-zagged on the political strategy of healthcare reform, leaving all concerned in doubt as to what he truly wants them to do. Trump has changed his healthcare approach 3 times in 36 hours, Julia Munslow, yahoo.com, 7/19/17.

He started off this week pushing for a “repeal and replace” plan, under which an alternative approach to healthcare would be promptly implemented. He later switched to advocating doing nothing, allowing Obamacare to simply “fail” and give him more leverage in negotiations. He then pushed for a so-called clean repeal, which would give the Republicans two years to figure out Obamacare’s replacement. Finally, on Wednesday, he returned to repeal and replace.

Observation: Such fancy footwork may have worked better for Mr. Trump as a real estate developer/entertainer than it has been working for him as president.

#SENATE REPUBLICANS - Was the president selling Senate Republicans short by underestimating the difficulty of their “mission impossible” to repeal and replace GovCare in a manner that would leave at least 50/52 Republican senators feeling satisfied? Some at the meeting probably thought so, but we disagree.

Government policy requires choices between competing ideas/interests, and “no brainer” problems (everyone agrees on the solutions) are relatively rare. Ducking tough issues because there aren’t any easy answers isn’t the way to get things done, it leads to gridlock and ultimately to failure. And just as members of the House Republican caucus may need to “take one for the team” now and then, the same should apply for Republican senators (some of whom seem to harbor an exaggerated sense of their own importance).

Not to pick on the Senate majority leader, but his low key, process-oriented approach hadn’t done much to pave the way for a Republican win on healthcare. Senator McConnell’s Obamacare debacle is an atrocious embarrassment, Chris Pandolfo, conservativereview.com, 7/7/17.

Who is to blame for the divisions in the Republican conference? Who drafted the bill behind closed doors and brought forward a plan that no one in the party is willing to defend? Who is the gatekeeper of the Senate rules that are preventing changes to the bill that could unify the conference? Mitch McConnell — who is using the Senate rules as an excuse for inaction and his poor leadership.

And the stated reasons of various senators for not jumping ship on the BCRA shouldn’t necessarily be taken at face value, e.g., the defection of the junior senator from Kentucky – based on his conservative principles, he was obliged to demand a clear-cut repeal of GovCare – may have been a function of political convenience.. Rand Paul, a man for all seasons on healthcare, Jonah Goldberg, townhall.com, 7/19/17.

Was it just a coincidence that the bill was terribly unpopular in his home state of Kentucky, where more than 1 in 5 Kentuckians are on Medicaid? *** When touting your principles is a politically expedient way of avoiding accountability, it's hard to tell whether principles or expedience is in the driver's seat.

#DEMOCRATS – Americans are supposedly sick of gridlock in DC, so why was the president dead set against any effort to enlist Democratic support for the healthcare bill? Perhaps this stance would make it harder to get a bill across the finish line, and/or leave Democrats determined to reverse whatever changes were enacted at the earliest opportunity. Republicans take tips from Obama, Hillary Clinton on how not to pass a bill, Noemie Emery, Washington Examiner, 6/27/17.

•The right way (FDR/LBJ): First of all, you don't do it quickly, but slowly and carefully. Second, you don't move before you know you appeal to a broad base of people. Third, you have to make it bipartisan [attract some votes from the other party], because nothing that isn't has moral authority. There is no type of reform that does not cause disruption, and bipartisanship is protection of sorts from the accusations of callousness that will surely ensue.

•The wrong way (BHO): In 2010, Democrats thought the heavy lifting was in passing the bill [which was done without a single Republican vote], and that after that people would love it, or at least become used to it. They never did. The Republicans now believe the same thing, though their plan is less popular now than the Democrats' ever was. *** Republicans should retreat for the moment under cover of fog, like the armies at Dunkirk, accepting that ‘now' may arrive just a little bit later. In the meantime, they have to read up about Johnson and Roosevelt, to learn how these things should be done.Realistically, however, Democrats view GovCare as the leading achievement of the Obama era, and their ideas for improving it seem limited to (a) injecting more taxpayer money to keep it afloat for the time being, and (b) completing a government takeover of the healthcare sector (by adopting a single payer system) when political circumstances permit. If Republicans are serious about achieving a more market-oriented and fiscally responsible outcome, they had better be prepared to force some changes while they are in the majority. A bipartisan deal on Obamacare is a pipe dream, James Antle, Washington Examiner, 7/19/17.

If you are looking for a compromise between single payer and the Republicans' preferred path, Obamacare (like its predecessor Romneycare) arguably is that compromise. Just not a sustainable one. Don't be surprised to see some bipartisan efforts to stabilize the exchanges ahead of the midterm elections. But the bigger problems with Obamacare will be solved over time on either Democratic or Republican terms. Not even an ideological chameleon like Trump can square this circle.

C. Likely outcome – To this point we have reprised the failure of Republicans to unite in support of a plan – any plan – to “repeal and replace” GovCare. We have also suggested that the president’s lecture to Senate Republicans was warranted under the circumstances, and the video shows it was capably delivered.

Hearing a message is one thing, however, and accepting it is another. And there is very little room for error (in the absence of Senator McCain, it would only take two GOP holdouts to block any healthcare bill Republicans might seek to bring to the floor).

As of Saturday, July 22, there apparently still wasn’t enough support in the GOP caucus for BCRA or any other healthcare bill (e.g., repeal now, replace later) that might be proposed. But with all senators free to offer amendments, it isn’t necessarily critical what bill is chosen. Next week: healthcare, border wall and a fight over war powers, Susan Ferrechio, Washington Examiner, 7/22/17.

"We are going to vote on whether to proceed to the bill," Majority Whip John Cornyn, R-Texas, told reporters Thursday. "I know people are fixated on what bill to proceed on, but every senator can offer amendments to change the bill, so it really is irrelevant. This is strictly about whether we are going to start the debate. People can offer amendments so we can finish at some point."

Like it or not, Republican senators who voted against the proposed healthcare bill would put themselves in the position of having voted to keep GovCare – hardly a popular position in conservative circles. Would they really feel comfortable doing so? Our self-interested senators, Kimberly Strassel, Wall Street Journal, 7/20/17.

. . . any Republican who votes against moving forward, “a motion to proceed,” will forever be known as the Republican who saved Obamacare. The Republican who voted to throw billions more taxpayer dollars at failing entitlement programs and collapsing insurance markets. The Republican who abandoned struggling American families. The Republican who voted against a tax cut and spending reductions. The Republican who made Chuck Schumer’s year.

Push come to shove, our guess is the would-be defectors will hesitate to vote against having a debate. And if a debate does take place, their arguments in opposition may well be exposed as phony. Ibid.

Voters would be able to see just how gigantic a Medicaid payoff Ohio’s Rob Portman, Nevada’s Dean Heller and West Virginia’s Shelley Moore Capito are demanding for their support. They’d watch supposed conservatives such as Tennessee’s Bob Corker vote against pro-growth tax cuts. They’d observe Utah’s Mike Lee offer up changes to Obamacare mandates, muster not even a dozen votes, and realize how unpopular his position is. They’d witness Kentucky’s Rand Paul vote against all reform ideas—no matter how good—because they still weren’t good enough for Rand Paul.

They’d see Alaska’s Lisa Murkowski cynically vote against the very same repeal-only amendment she supported in 2015, back when it didn’t matter. They’d see South Carolina’s Lindsey Graham and Louisiana’s Bill Cassidy cast the only two votes for a bill they’ve been pushing—and confusing everyone with—for weeks.

At the risk of sounding like cockeyed optimists, we predict that a Republican healthcare bill will result from this process. If you share that hope, pass it on!

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#Some Rs and all Ds will try to hang onto their phony jobs by not voting for tax cuts or healthcare reforms. – SAFE directorPerhaps, but at least there will be a Senate debate on healthcare (as was determined by a 51-50 vote onJuly 25).